Conundrum of Consultation.

Few years ago a fellow physician asked me to see a patient. When I asked him why he said “STP”,  he chuckled and said “for STP, share the pain”.

As a hospitalist, medical consultation is one of the essential components of our work. Various specialists require assistance in areas which are beyond the scope of their expertise. So, an orthopedist may want a hospitalist to manage infections or diabetes or a cardiologist wants us to evaluate a patient for abdominal pain. The reasons could vary. Some are from orthopedist, some from cardiologist etc….. 

They vary from atypical chest pain to coagulopathy. Most of them are very appropriate and we love to tackle medical problems of all sorts. But then there are some consults which are called for all the wrong reasons.

Interestingly when you look at the reason for consult, mostly it is a very vague reason like “medical co- management”. However, at times when you ask the nurse the reason is entirely different.

Don’t take me wrong, most of the times physicians need assistance like if someone is septic, they want a hospitalist or intensivist to take over the case. If someone has brittle diabetes, they want an opinion for better glycemic control. But some times the consult could be just STP (share the pain) or just indifference. At times  referring physician just want someone else to do their scud work. 

However, regardless of nature of the consult you would almost always find this statement at the end of dictation “Thank you for allowing me to assist you in this very "interesting patient”"

I will give you some very “interesting” consults I have received in the past few years.

-      A nurse called me for a consult for “medical co management”. I asked her what the story is? Apparently patient was very belligerent towards the attending physician. After the attending physician left patient wanted to leave against medical advice.  Nurse called the attending physician; he did not want to be bothered. When she asked for further direction, he said lets call for a hospitalist consult. That left me very perplexed. What am I suppose to do, get a couch, asks the patient to lie down and provide behavioral counseling?

-        I was called for diabetes management on a chest pain patient. When I came down to evaluate the patient I found out she was a 91 year old lady with hospice for terminal lung cancer. Apparently EMS brought her to the hospital while they were on their way to hospice house from nursing home. In the ambulance she started to moan. EMS thought it was a good idea to stop at the hospital. ER physician decided to admit this hospice patient.  On the whole scheme of things diabetes was the least of her problem. I spoke with the family and transferred her back to hospice.

-        Sometimes the consult is called because the surgeon or a refereeing physician does not want to perform medication reconciliation or discharge paperwork; we are consulted for “hypertension”, when patient is on a hint of diuretics for hypertension. They just don’t feel like doing it I guess.

Now on the other hand I would rather be a consultant on some cases than being the primary attending. Few years ago I was called to admit a 42 year old man with chest pain due to a thoracic aortic dissection. After ER physician finished presenting the case I asked him “do you think I have some divine connections, if you want I can come down and pray for this patient at bedside, as I am surely not a cardiothoracic surgeon and you want someone who can crack open his chest”.

Sometimes when I am being consulted I feel transiently important, it is good for my ego that they want my opinion. On the other hand I think we need to have very clear and defined reason for consult, not just “co- management”. This would not only improve care but also clearly focus on the specific issues which need to be addressed. Like the other day I saw a patient for “co-management”. Later found out that the physician was concerned about the side effects of a certain medication. I missed it completely as this was not mentioned nor conveyed to me at any time.

I can see how we need to improve communication from our side. This is an ongoing project at this time.

PS: About the picture: This is not a magic ball. Inside Vatican Museum.

End Of Life Issues.

When I saw my first patient die, I was in shock. I knew that some will die but you are not really ready until you see one. You will never forget your first one, that always stays with you. When my first patient died during medical school;  a young guy around forty. He died from complications of Endocarditis. He was fine in the afternoon, talking about his family and what he does, when I came back in the morning he was gone. I was shocked beyond words. Unfortunately with time and age you get used to it. We adapt and move on but still end of life issues are difficult to deal with, even for the most experienced doctors.

I wrote about the role of hospice here earlier. But there is a transition, a process which ends up with hospice or no code status, but this process starts when a physician starts talking about end of life issues.  

During my training at UMASS, we were taught to always inquire about the code status at the completion of history and physical. This included either a Full code, DNR (do not resuscitate) or CMO (comfort measures only) status. However , most of the time this discussion is delayed until it is too late in the game. 

Some of the pitfalls I see in this matter are:

1- Physicians are a little weary about inquiring the code status. There may be a certain level of apprehension as they think that the patient may loose confidence in them if they ask this question. 

2- Patients may get angry as we all know that we will never die.

3- Often I hear physicians asking patients "do you want us to do everything". In this scenario physician assumes that the patient does not want to die.  Information is not carried to the patient properly and the patient makes a vague statement "yes", But the question is yes to what? However, code status is entered in the medical record as Full code.

I am not saying that I am an expert in this issue. Usually this is how I ask them after I am finished with history and physical that "I would like to ask what I ask all my patients, what are your wishes in case your condition deteriorate, I don't want to do any thing which is against your believes and wishes". 

You need to ask the patient how they feel or understand about their condition, otherwise it becomes a one sided discussion without giving the patient an opportunity to discuss their perspective.

If they decide to be DNR, then I go over various options which a person can choose from refusal to blood transfusions to refusal of basic CPR or intubation.

It is important to give patient time after each statement for two reasons a) It gives times for the information to sink in and b) it gives physician some time to read patients reaction and some space to to maneuver words to soften the impact.

All in all this is a very important process and physicians need to be more proactive about this process.

Blog you later.

About the picture: I woke up at 5 am to run to Na' Pali coast, Kauai when I saw this sunrise at the beach.

Hospitals Cannot Cure Some Pain. Hospice.

It was a dimly lit room, up on the sixth floor.  I am not sure why they would not fix the light in that corridor. Even during the day, I would find this area poorly lit. Maybe it was not the light but the grim atmosphere of Oncology floor. Some of the patients there were with terminal illnesses and they would still act like they had decades to live for. You will be surprised how you find bravery at unexpected places. Maybe they were not really brave but pretending to be, I could never find the difference.

How do you find such strength? Maybe they are hopeful that they would get better, maybe they will get few more years to wonder this road. Hope keeps us going… I guess. Their optimism was like a breeze in the garden, which surrounds you in a subtle way. Those were one of the times you want to forget the statistics and all that prognostic data and just reassure them. You want to tell them that survival numbers are just numbers which mean nothing.

He was a resident of the sixth floor. He had mesothelioma, suffering with pain, not the kind of pain which can be cured by medications. He was leaving his family, for good. For some it is a passage from one phase to another, for some it is the end of the line. Some believe that they will come back as better or worst. No matter what they believe… we all go cross over. He worked in an asbestos factory for the most part of his life which eventually caused his cancer. Once I asked him sitting down next to his bed, has he ever thought about suing the company he worked for, he said no, he was supposed to die one day anyway…. so be it.

I offered to increase his medications to improve pain, he said “the kind of pain I have, you do not have the medications for it yet”. I think he was right. His son requested us to keep him comfortable. He wanted him not to suffer. In the end he requested to be released home, he said “I would rather die with my loved once; I have had enough of these hospitals.

And I think this is where hospice plays a very significant role. As much as we are trained to prevent death, we are not trained to deal with it. One of my professors actually said “death is just a phase, one to another”. He actually lost his wife to ovarian cancer. I learnt a lot from him about end of life issues. He said “sometimes we love our loved ones so much that we are not willing to let go of them for our own selfish reasons”. I try to tell my patient families to think from the patient’s perspective rather than their own. Who would like to be lying in bed with all kind of tubes sticking out? Versus dying in peace

These days there are fellowship available in Hospice medicine and palliative care. They teach and train principles which embraces compassion, integrity and ethical views to take care dying patients. There is a misunderstanding that patients with cancer can only be a part of hospice. Actually patients with terminal diseases of any kind, advances dementia and gravely ill patients can be enrolled in these programs.  We just need to realize their need and the great service they provide.

About the picture: Dwindling lights.

Medicare Cost and Million Gazillion Dollars.

Recent new estimates from US government reported a 17.3% increase in health care spending as compared to the previous year. This is the largest jump in half a century. 2.5 trillion spent on healthcare was 134 billion more than last year. These are very huge numbers, beyond my comprehension. The way I see it they will continue to grow.

How we contribute to this cost, is best explained in the words of a patient I recently admitted.

ER called me regarding a patient who was unresponsive. She was in her late eighties. Patient had a comprehensive work up including labs, chest x-ray, EKG, cardiac enzymes and CT of the brain. These entire series of tests were predominantly negative.

When I saw her on the floor she struck me as all gray, her hair was all gray, skin ashen and face pale; like a flower dying slowly. She was still not responding to any commands, I saw that there was an order for a MRI of the brain and carotid ultrasound. After examining her I reviewed the records in the chart from the nursing home and among other things there was a DNR (Do Not Resuscitate) order in the chart.

I called the son and he asked me, what his mother was doing in the hospital. I told him about her grim status. He informed me that she was always good to him, he was her favorite.  She had started to deteriorate once dementia started to set it.   Now she had been non verbal for a year. She was like an empty shell. He decided to enroll her in hospice a year ago. I assured him that I will call hospice. Within few hours hospice saw the patient, I cancelled all pending labs and test and she was transferred to nursing home with hospice. 

Hospice patients just want to be comfortable, they do not want any heroic measures or any further diagnostic test. Even within twelve hours of her stay in the hospital, Medicare will be billed probably more then 15 grand, excluding bills from EMS etc. All of this could have been saved if someone had paid more attention to her code status at the nursing home, ER or on the floor.

The sad part is not just the cost of care but taking the opportunity away from some loved one to die in peace rather than dying with tubes coming in and out of you.

About the picture: I shot this at my backyard.